OBJECTIVES: The artificial urinary sphincter (AUS) remains the ′′gold standard′′ for the treatment of post prostatectomy stress urinary incontinence (PPSUI). However, in recent years, minimally invasive, less expensive sling device (AdVance) are offered as potential alternative treatments. We sought to investigate the long-term cost-utility of the AUS compared with Transobturator Retroluminal Repositioning Sling (AdVance sling) in the treatment of severe PPSUI. METHODS: A Markov model with Monte-Carlo simulation was developed to estimate the incremental cost-utility ratio (ICUR) of AUS vs. AdVance sling from a provincial payer perspective over a 10-year period. Probability estimates, success rates, healthcare resources and utilities were obtained from published literature when available or by expert opinion. The Markov model included 4 states (wet, post-wet, dry and death). Costs for disease management and devices included in this model were obtained from provincial databases in Quebec, Canada and hospital database. Uncertainty was analyzed using deterministic and probabilistic sensitivity analysis.RESULTS: AUS Implantation had a 10-year mean total cost of $14,300 (SD±3,509) for 7.64 QALYs. On the other hand, AdVance sling had a mean total cost of $17,042 (SD±12435) for 6.53 QALYs. The cost-utility analysis showed that AUS becomes a dominant strategy when compared to AdVance sling over 10 years. The incremental cost savings of AUS was $2,742 with an added effectiveness of 1.11 QALYs. The probability of becoming wet after an AdVance sling as well as the probability of going through AUS after an initial surgery with AdVance sling demonstrate the most variability compared to base-case ICUR in one-way sensitivity analyses. (751,16$ and 437,07$, respectively).CONCLUSIONS: Although the initial cost of sling is attractive, superior long-term outcomes are demonstrated with durable high success rate of AUS in men with severe PPSUI. Hence, the AUS implementation strategy over a 10-year period time is estimated to be more economical to our health care system.